GW1-2023-00466_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
50 ft- 165 ft.
3254 A . ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING{for multi cased wells OR LINER if a Gcable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESSI MATERIAL
0 ft- 83 ft- 16.25 in- SDR21 JPVC
Company Name
323447 16:INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply 1 Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.' in.
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. tt
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 IL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. •ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG attach additional sheets if necessu
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollfrork rain size,etc.)
0 ft. 78 1- Dirt
4.Date Well(s)Completed: 8-25-22 Well ID# 78 tt. 165 It. Rock
ft. ft
5a.Well Location:
Jeffery Robinson ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
530 Shiloh Rd, Statesville, NC 28677 ft. ft. AIN
Physical Address,City,and Zip ft. ft. w
Iredell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C 'lineation:
35' 73.662' N 080' 82.989' W - 12/22/2022
6.Is(are)the well(s): iMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I`JNo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.SIte diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (ft.) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
It.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636,MSC,Raleigh,NC 27699-1636
12.Well construction method:Air For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: i r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/3 cup
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018